Tag: Planning a VBAC

At some point during a VBAC journey, it is likely you will start a love affair with stats. I know, because I’ve been there. I’ve courted stats, I’ve had lover’s tiffs with stats and, I’m pretty sure, I’ve even taken them to bed.

So, here follows a lengthy discussion which – if you choose to read it – may mean you won’t be able to read another VBAC success stat again without picturing a dancer on a pole. (And yes, you can thank me later.)

The Love Story Begins

While you’re waiting for the retails stores to have crystal balls on special, having facts and figures upon which to base your decisions is the next best thing, right? And, who doesn’t love a sexy stat or two, especially when they tell you what you want to hear.

In fact, I think stats can do even more – with the right stats, you might gain some credibility in your discussions with a care provider, for example. Stats might even lead you to make a critical choice which is the difference between the birth outcome you desire and the alternative. And, in this day and age, we plebs have even more stats at our fingertips than ever before – this is perhaps our greatest time of empowerment. Repeat after me: COLLECT ALL THE STATS!

But, stats – like all forms of information (and indeed all new relationships) – need to be approached with certain level of caution. Like any meticulously constructed Instagram account, the best looking stats have possibly been cropped and filtered to create a certain outcome. And, like that Instagram pic which crops out your ‘shagbuster’ trackies, stats only tell you part of the story you want – it is your job to gather the rest of information you need to give these numbers *context*. (Because, let’s face it, everyone secretly only wants to see the stuff that is cropped *out* of Instagram pics, right?)

Let’s take a popular general statistic like ‘women have a 75% chance of VBAC success’. This might fill you with confidence for your planned VBAC. Indeed, it *should* give you confidence in your decision to plan a VBAC, because it sounds pretty darn good. Crikey, if I were told I had a 75% chance of winning lotto, I’d be actually getting dressed today (and that’s saying something!) and heading out to my local newsagent to buy myself a ticket.

However, here’s the catch: this statistic is the promise of an outcome, not a guarantee. (Darn it – I might have just gotten dressed a little prematurely! Never mind – Instagram will help me to crop my shagbusters out.)

And, here’s a harsh fact: Not all women have an equal 75% chance of successful VBAC, just like not every punter has an equal chance of winning lotto. This is an average, a OSFA number. It is a handy number to know, but it is not necessarily your Magic Number. We logically know that my chance of winning lotto goes up and down depending on which numbers I choose (if i do indeed choose my own numbers), and how many tickets I buy. In a similar way, some women are more likely to VBAC than others.

Harsh Fact #2: The effect of your choices on your Magic Number is really only ever known retrospectively. This is the awful truth about stats – sometimes they’re all talk. But, sometimes they turn out better than you thought.

So, while you’re in the thick of it and don’t yet have the benefit of hindsight, let’s at least try and make this stat work a little better for you. And, how do you do that? You need to work it, baby! Think of yourself as the RuPaul of the VBAC Stat World! You need to go forth like the fierce mama you are and get more information to frame this number within your own context (feel free to leave the killer heels and spandex to RuPaul, however – I much prefer ugg boots and jeans!). Don’t leave this stat standing there, naked, shivering and pleading for a coat – dress it up in the important stuff, like ‘who is my care provider?’ and ‘where am I birthing my baby?’

As you start adding details to the 75% stat, watch your Magic Number bounce up and down. Truthfully, I have a dance pole in mind here with this… And now so do you. (I did warn you!).

Think of 75% as the sweet zone on the pole. When you jump on, you might be a bit rusty and find yourself at about 45%. That’s okay – the beauty about VBAC is that you have at least nine months to do something about that. So, you start researching, making choices and asking questions. This is you climbing a little higher. You go back to your obstetrician and hear that they have an 80% VBAC rate. You beauty! You climb higher. But, after reading about the difference between VBAC rates and success rates, you ask your obstetrician how many VBACers they oversee – their answer is five in the past year. Uh oh, your Magic Number just slipped a little. You then get to your 36 week review and your care provider starts mentioning ‘big baby’, ‘small baby’, ‘low amniotic fluid levels’, ‘high amniotic fluid levels’, ‘due dates’, ‘going over’… Yikes, suddenly you feel like you’re at risk of face-planting on the tacky floorboards beneath you. (Actually, so is the landlord – they’re stepping in to stop the show lest it becomes a public liability claim.) (And yes, this landlord is a metaphor for a ‘bait and switch‘ care provider – they do exist.) So, you quickly change tack, get a second opinion or two and make some new decisions… Phew! You might have just avoided a repeat Caesarean (and an insurance claim).

You see, the VBAC success rate is not guaranteed until *after you give birth* (and you jump down from the dance pole). This is actually good news!

Don’t think of a VBAC success stat as a static number – it is a fluid thing. The birth choices you make, the preparation you do, and the support you have around you all shift this number up and down. Stats are great to help you understand what are reasonable expectations – they help you to make the best decisions possible when the crystal ball you bought online from China is caught up in the Australia Post Christmas rush. But, at the end of the day, stats are numbers which can be sliced and diced numerous ways for various agendas – like any good relationship, it is important to remember that you have control over what you bring into the picture, too.

If you’re a South Australian mother researching VBAC, chances are that you’ve stumbled across the Pregnancy Outcome Unit’s‘Pregnancy Outcome in South Australia’ reports. (If you haven’t already, you just did.) Seriously, if you love stats which are actually *relevant to a local context*, these publications are to the World of VBAC Stats what Pana chocolate is to the world of cocoa-based confectionery. (And, if you haven’t yet stumbled across Pana chocolate, make sure you do – it will help you stay up late reading stats.)

Whet your appetite!

Now, these documents are really a bit of a beast. There is so much information in them that they are best consumed piece by piece (a bit like Pana chocolate). It pays to pace yourself – take notes, highlight things, digest them. Come back in the morning with fresh eyes and re-read them again. Take more notes and eat more chocolate.

One of the tastiest pieces of information for a VBACer is found under ‘Clinical and Maternity Performance Indicator: Vaginal Birth following Caesarean Section’ (shortened to ‘VBAC’ when ‘VBFC’ would actually be correct in this case… I guess it makes it sound like VBACers have their own footy club, though). This is where you will find the magical number which answers the question: ‘How many women VBAC in SA?’

Let’s hold that thought – how far through that block of Pana are you right now? Is it still tasting sweet? Is it melting in your mouth and slipping down your throat like a silken river caressing your insides? Well, enjoy that, because what I’m about to say will leave a bitter taste in your mouth.

For years, the VBAC rate in South Australia has consistently been at about 17%. (And, if you’re playing from interstate, the national rate is usually around 16% – you can track this in the Australian Mothers and Babies reports.)

I can hear you suddenly choking on your chocolate. What?! Did I read that correctly?! Only 17% of VBACers actually VBAC? And, because you’ve read them: Don’t the South Australian Perinatal Practice Guidelines cite a VBAC success rate of 72-76%??

STOP!

In the name of (stat) love, I want to make a really important point whilst you catch your breath…

The reported rate of VBAC in these cases IS NOT A VBAC SUCCESS RATE. This is simply the rate at which women in a defined cohort VBAC. Assuming these two things are synonymous is like thinking you can subsitute Cadbury for Pana (which, I assure you, you cannot).

A hypothetical

Take a group of 100 women who are potential chocolate connoisseurs. Sarah Wilson has successfully reached 66 of these women, so they have no interest in eating chocolate. 34 of them are after a sugar-fix and indicate they’d like to eat Pana, but 17 of them get Cadbury and the other 17 get Pana. The overall rate of Pana chocolate distribution is 17%, but the rate of successful distribution to the women who wanted it is 50%. So, whilst Pana sales aren’t as great as they could be, it’s maybe not so bad because half of the women who wanted Pana got their fix. (And, from Sarah’s perspective, these stats are looking pretty damn fine.)

Take a group of 100 women, 34 of them plan a VBAC and 17 of them go on to have a VBAC, this means:
– The VBAC rate for this group of 100 women is 17%
– The VBAC *success rate* for this group of women is 50%.

To make my point – taking the VBAC rate of 17% and describing it as a *success rate* is categorically incorrect. VBAC rates and VBAC success rates are *two different sets of stats*.

Furthermore, the group of women in this cohort are “women giving birth vaginally following a previous primary (first) caesarean section and having NO intervening pregnancies greater than 20 weeks gestation.” Do you fit the bill? If you’re having a VBA2C, this stat might be of little relevance to you. If you’re planning a second or third VBAC, you might also feel the need to find this information via other avenues.

So, how do we find out more about VBAC success rates? Well, until our health bureaucrats start recording how many women *attempt VBAC*, we will not know what the success rate is. The best thing you can do here is to ask your care provider AND hospital two questions:

– What is your VBAC rate?
– What is your VBAC success rate? (Otherwise known as ‘How many women in your care attempt VBACs? How many of these go on to VBAC?)

Further Food For Thought

Once you have a VBAC success rate, is it going to satisfy your craving for reassurance? Possibly, but maybe not.

Think about this: if an obstetrician has an 80% success rate, he/she sounds like a keeper, yeah? What about if this obstetrician only oversaw 5 attempted VBACs in one year, 4 of which were successful (hence the 80% success rate)? Does the stat indicate this care provider is skilled and experienced at attending VBAC, or does it simply suggest that this care provider lucked out? And, just whose ‘success’ is this stat, anyway?

The message you can take home in a foil swan

Stats are great to help us get our heads around the unknown, to get a feel for birth culture and to play to our best odds. But, it is really important to read the fine print – adding the word ‘success’ to what is simply a VBAC rate creates a BIG difference. Having the confidence to question stats, care providers and ‘birth experts’ takes intestinal fortitude, but seeking accurate information from a variety of sources makes for a balanced diet… Even if it is predominantly made up of Pana chocolate when you do the number-crunching!

1. No major abdominal surgery!!
2. No trying to recover from aforementioned major abdominal surgery whilst also caring for a newborn and other children.
3. Emotional healing: for many (myself included), VBAC births are a positive step towards healing previous birth trauma.
4. Good for your baby: passage through the birth canal helps innoculate your baby’s gut with the variety of flora it needs, helps to ‘awaken’ your baby’s body and activate many of his/her physical systems ready for life outside the womb.
5. Breastfeeding is easier: no grappling with numbness, IV lines, pain or delayed milk.
6. The physical high: you know those memorable moments in the bedroom? Combine those and multiply by 100.
7. Satisfaction: knowing your body is not broken, your pelvis is not too small, your body knows how to birth, and being able physically complete the job your body has been working on for 9 months (or more, if you’re me!).
8. Up and at ’em: being able to eat, drink, walk and feel lucid within hours of delivery definitely gives VBAC an edge and facilitates early bonding with your baby.
9. Delivering your own placenta: this brings a new dimension to birth, particularly if you’ve never done this before, and can give a new appreciation of the amazing things your body can do (like growing an organ from scratch!).
10. The feeling of pushing a baby out of your body, pulling his/her slippery body up onto your chest and enjoying that moment of mutual discovery – truly, there is nothing like it.

As I mention in ‘Empowered Birth is Not In The Eyes of the Beholder’, one of the most disempowering assumptions to be made during a planned VBAC is that ‘a healthy baby out of my vagina’ is all that matters – this is a great and logical foundation for a bigger goal, but the process of planning a VBAC should not only be about babies and vaginas.

Here’s where I’m going with this… What if that baby comes out of your vagina, but you have to have an assisted delivery? What if that baby comes out of your vagina, but you are coached to push? What if that baby comes out of your vagina, but you feel totally out of control because your body takes over? (Google ‘foetal ejection reflex’ if you haven’t already.) And, what if you unexpectedly decide that you want to have a repeat Caesarean?

The passage of your next child through the birth canal is not automatically a passport to empowerment. Sometimes women ‘get their VBAC’ and yet still report feeling disempowered for various reasons. Conversely, others end up with unplanned repeat Caesareans and yet feel perfectly empowered during their birth. These are some of The Grey Zones of Empowerment.

Instead of focusing solely on the mode of delivery of your planned VBAC baby, have a think about how you want this birth to feelfrom your perspective. Yes, by all means plan to birth your baby vaginally – there are, after all, many benefits associated with vaginal delivery! But, don’t stop there – also plan to be empowered.

If you plan to be empowered, the fear of ‘What if I don’t get my VBAC?’ can disspate. Reducing fear ahead of a planned VBAC is actually an integral step towards VBACing! And, if you can say – I know what it feels like to be empowered, then, congratulations! This is about as close as you will possibly get to guaranteeing yourself a positive birth experience next time, which is right where we want you!

The Empowerment Ride Doesn’t Stop Here!!

The awesome thing about the VBAC journey is that it does not have to end with the birth of your baby. The things which we learn through the process of actively planning an empowered birth are, like many of the lessons of motherhood, transferable and applicable to many aspects of ‘Life After VBAC’. Empowerment during birth is the same as empowerment in life – once you’ve discovered your portable power, you can use it to make good decisions about anything.

Because we are not taught to cope well with ‘unknowns’ in life (and because the VBAC journey is full of them), it can be tempting to look for a ‘VBAC by numbers’ solution thinking also that a VBAC will automatically be an empowering experience in and of itself. And, I totally understand why this shortcut is so tempting, especially when we all have small children, minimal research time and a craving for VBAC Hacks which will make life easier!

The ‘VBAC By Numbers’ set of instructions for empowered birth often looks like this:

All of these steps are absolutely important and integral to planning an empowered VBAC. Everyone who is serious about planning a VBAC is well-advised to work through these things (plus a few extras which I will cover in a separate post!). So, please do go forth and consider doing at least one, some or all of these things.

However, here’s the harsh reality check… Ticking off all of these things and then assuming this will guarantee a VBAC outcome and/or an empowered birth is, unfortunately, ironic. Whilst a VBAC preparation list is something you can google and work through without any personal reflection at all, if you miss that opportunity for personal reflection, you have also missed a chance to practise being empowered.

The other problem with the ‘VBAC by numbers’ mentality is the danger of switching one form of outsourced responsibility for another – if you blindly follow a ‘How to Plan a VBAC’ list, you are not necessarily any better off than you are when blindly following the advice of a care provider. If you want to be empowered, you must question everything (including this blog post!) and come toyour own conclusions. The second you stop thinking for yourself is the second you risk becoming disempowered.

Working through any list of dot points (like the one above) is totally fine as part of an ongoing process – a work in progress which is your own journey to empowerment. But, once you’ve exhausted the ‘How to Plan a VBAC’ list, keep going! Stay open to the possibility that, with every layer you work through, you get closer and closer to an empowered birth.

It can be really tempting to make assumptions that certain sets of birth choices are more empowering than others. A common image of ’empowered birth’ often features a birthing woman who, supremely fit and healthy, labours like brave, primal warrior whilst being attended by her ‘sisters’ and a patient, strong partner. This is, indeed, a picture of empowerment which resonates with many of us and it is something to which we aspire. Images of women dressed in hospital gowns, attended by doctors and placed under the bright lights of a typical hospital room are far less appealing to the heart strings.

But, what if empowered birth can actually happen in a hospital gown? What if it’s possible that a birth among ‘sisters’ might feel disempowering? Are we doing women a disservice when we present one version of empowered birth as the only version of empowered birth?

The thing is, no single image will ever universally capture what it is to be empowered in birth because personal empowerment comes from within.

Personal empowerment can definitely be influenced (for better or worse) by a range of external factors. A doula can be a good ‘empowerment coach’, a traditional midwife can facilitate empowerment by simply holding the space, a partner can support empowerment by advocating for you when you cannot do it for yourself…

But, much like birth, the act of becoming empowered, whilst aided by all of these external factors, is essentially a task one must complete alone. This might sound a little scary, and it certainly takes some practice (like any new skill), but don’t let this put you off – learning the art of self-sufficient empowerment gives you the gift of portable power. Once you know what personal empowerment feels like, you can pack it into your birth bag and take it anywhere, regardless of your destination.

For women, this concept of portable power is an important one to understand. You need to know that your birth choices do not automatically empower you. A woman-centred doctor or midwife cannot empower you, a nice, ‘homely’ hospital room cannot empower you and making what is considered by others to be ‘empowered decisions’ does not empower you. And, why not? Because you empower yourself.

For those attending birthing women, we need to remind ourselves of the internal nature of empowerment and the goal of portable power which lies at woman-centred care – just because a woman has made the set of choices which an empowered woman generally makes, this does not mean she is herself empowered. Judging external factors as evidence of a woman’s personal empowerment (or disempowerment) ironically robs the birthing woman of the opportunity to find and define her own power (and thereby become empowered). Why? Because only she alone can empower herself.

Now, in the interests of maintaining my portable power metaphor above, I invite you to pack your bags and take a short trip with me into The Grey Zone.